Drug seeking or real pain? How do you tell?
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I'm a new nurse on the list so please pardon my ignorance. I was quite interested in the pain links and explored several and probably will use some for staff training. I did not see any mention of... Read More

If a patient is seeking drugs but has no pain physically, mentally he has a lot of it. A nurse is never in the profession to play judge and jury. The best thing you can do is have belief in your patient and not judge. You ask how can you tell. I don't really think you can.

If a patient is seeking drugs but has no pain physically, mentally he has a lot of it. A nurse is never in the profession to play judge and jury. The best thing you can do is have belief in your patient and not judge. You ask how can you tell. I don't really think you can.

Pain is subjective!!!!!!!!! Should I say that again, SUBJECTIVE. Unless the DOCTOR has documented proven evidence that a pt is purely drug seeking, then they have pain.Even with that evidence, they still have pain. Now what is also subjective is pain tolerance, your 10 might be my 5.We need another scale of some sort. Sorry this angers me so. Until you have been at the oposite end of someone questioning your pain, or maybe your loved ones, you will have no idea. We are not the judge and jury. The one time you withold something or pass someone over instead of acknowledging their pain, could be the time that something acute is being missed.

Pain is subjective!!!!!!!!! Should I say that again, SUBJECTIVE. Unless the DOCTOR has documented proven evidence that a pt is purely drug seeking, then they have pain.Even with that evidence, they still have pain. Now what is also subjective is pain tolerance, your 10 might be my 5.We need another scale of some sort. Sorry this angers me so. Until you have been at the oposite end of someone questioning your pain, or maybe your loved ones, you will have no idea. We are not the judge and jury. The one time you withold something or pass someone over instead of acknowledging their pain, could be the time that something acute is being missed.

And as long as you rely completely on subjective that will not change. Like the cute little brunette last night, flapping her eyelids, smiling sweetly, in no distress, "My pain is a 10" We as nurses are held against our will to a subjective pain scale by patients who have learned to manipulate it, to get drugs. I realize this, I accept this, I never get angry about this.
Our triage sheet has stated pain scale, and face pain scale to document on if you like. I have charted pt stated 10 with quotation marks on stated , and written zero on the face scale.

And as long as you rely completely on subjective that will not change. Like the cute little brunette last night, flapping her eyelids, smiling sweetly, in no distress, "My pain is a 10" We as nurses are held against our will to a subjective pain scale by patients who have learned to manipulate it, to get drugs. I realize this, I accept this, I never get angry about this.
Our triage sheet has stated pain scale, and face pain scale to document on if you like. I have charted pt stated 10 with quotation marks on stated , and written zero on the face scale.

Ok ,I can relate to this,but what happens when u get someone who has never had pain? Some people say a hang nail is a 10.and others who could have an open fx and they are saying its a 5. Everyone's backround with pain is different. It always has to be subjective,sorry. What helps correlate pain level is with physiological reaction to pain. Even if the pain is "just" withdrawal. Vital signs will always show some reaction to pain.
If things do not add up and they r still c/o severe pain, I ask a few questions and also state we will be doing a urine for tox to help us keep them safe. When approached in a non judgemental manner, most will own up to what they are on,and why they r there. I tell them we can not care for them safely unless we know what's really going on. Now granted u will get some who could con a nun out of her habit, but many will own up. Sometimes u hear bstories that change own's attitude . It's not a perfect bsystem and ER nurses see so much abuse, but I still say u have to believe untill u could say in a court of law u nknow otherwise. Then there'sletting the doc handle it,,,lol

Ok ,I can relate to this,but what happens when u get someone who has never had pain? Some people say a hang nail is a 10.and others who could have an open fx and they are saying its a 5. Everyone's backround with pain is different. It always has to be subjective,sorry. What helps correlate pain level is with physiological reaction to pain. Even if the pain is "just" withdrawal. Vital signs will always show some reaction to pain.
If things do not add up and they r still c/o severe pain, I ask a few questions and also state we will be doing a urine for tox to help us keep them safe. When approached in a non judgemental manner, most will own up to what they are on,and why they r there. I tell them we can not care for them safely unless we know what's really going on. Now granted u will get some who could con a nun out of her habit, but many will own up. Sometimes u hear bstories that change own's attitude . It's not a perfect bsystem and ER nurses see so much abuse, but I still say u have to believe untill u could say in a court of law u nknow otherwise. Then there'sletting the doc handle it,,,lol

There is a certain manipulative behavior, very similar to that seen in some mental illness, that a drug seeker will demonstrate.

While in the ER, they know they don't have time to play the game slowly, so in the course of a couple of hours you may see: try to befriend you while complaining about everyone else's insensitivity; whine, cry, scream in pain at eardrum shattering levels; report you; play helpless and needy; play the misunderstood one; educate you; become verbally abusive & occasionally physically abusive; have a tantrum or two; apologize and state that they really didn't mean to be [whatever]; try a few attention getting stunts [accidently pull out the IV, wet the bed, get tangled in the sheet, fall, etc]; try to turn staff against you; enlist the help of a codependent friend or family member; set the days record for the amount of time the word 'nnnuuuurrrrrse' was yelled out ...

I do have to admit that sometimes I find the inept manipulator amusing and have fun with it. It's probably a survival thing.
For instance: I have an allergy to dilaudid IV and PO, demerol and po morphine. The only thing I can take is IV Morphine and anything less than 6 mg doesn't help my 15/10 back pain.
What happens to you when you have morphine pills?
I get hives and my throat swells up.
Well, the doctor has ordered the Morphine injected into your muscle.
I can tell you now that it's not going to work, I'm just going to be allergic to it.
How do you know for sure?
I just know
Post IM injection, pt seen rubbing the site and hitting it under the sheets
NNNNUUUURRRRSSSSE
What is it?
See, I'm having an allergic reaction?
Are you sure?
Yes I'm sure!
Do you want me to document it as an allergic reaction?
Yes. Now can I get the Morphine IV?
Don't think so because you are probably allergic to all opiods and I don't think the doctor's going to order something going into your vein that you are now saying caused you an allergic reaction. I'll go tell the doctor.
Nurse, wait, you know what, I don't think I'm allergic to what you gave me, I was lying down on it and I think it just fell asleep, see, see how better it is looking.
Sorry, we can't take a chance that you'll have an bad reaction-I'm going to get the doctor and let him decide.
Talk to doc & he comes to bedside: I see here on the chart that you said to the nurse to report the redness where you got the injection of morphine as an allergic reaction, is that the way it was?
No, the nurse must have misunderstood me.
Pt on other side of curtain yells out : everyone here heard her yell at the nurse to report it as an allergic reaction, she hasn't shut up for over a half hour now.
Doc: Sorry, but we can't give you anything that you might have an allergic reaction to.
I'm leaving, nobody listens to me, nobody cares about all the pain I'm in and how I can't walk (while standing up, putting clothes on over the gown and trying to storm out)
THIS IS A TRUE STORY (I left out some things and changed /deleted medications that might be too specific to the patient).

There is a certain manipulative behavior, very similar to that seen in some mental illness, that a drug seeker will demonstrate.

While in the ER, they know they don't have time to play the game slowly, so in the course of a couple of hours you may see: try to befriend you while complaining about everyone else's insensitivity; whine, cry, scream in pain at eardrum shattering levels; report you; play helpless and needy; play the misunderstood one; educate you; become verbally abusive & occasionally physically abusive; have a tantrum or two; apologize and state that they really didn't mean to be [whatever]; try a few attention getting stunts [accidently pull out the IV, wet the bed, get tangled in the sheet, fall, etc]; try to turn staff against you; enlist the help of a codependent friend or family member; set the days record for the amount of time the word 'nnnuuuurrrrrse' was yelled out ...

I do have to admit that sometimes I find the inept manipulator amusing and have fun with it. It's probably a survival thing.
For instance: I have an allergy to dilaudid IV and PO, demerol and po morphine. The only thing I can take is IV Morphine and anything less than 6 mg doesn't help my 15/10 back pain.
What happens to you when you have morphine pills?
I get hives and my throat swells up.
Well, the doctor has ordered the Morphine injected into your muscle.
I can tell you now that it's not going to work, I'm just going to be allergic to it.
How do you know for sure?
I just know
Post IM injection, pt seen rubbing the site and hitting it under the sheets
NNNNUUUURRRRSSSSE
What is it?
See, I'm having an allergic reaction?
Are you sure?
Yes I'm sure!
Do you want me to document it as an allergic reaction?
Yes. Now can I get the Morphine IV?
Don't think so because you are probably allergic to all opiods and I don't think the doctor's going to order something going into your vein that you are now saying caused you an allergic reaction. I'll go tell the doctor.
Nurse, wait, you know what, I don't think I'm allergic to what you gave me, I was lying down on it and I think it just fell asleep, see, see how better it is looking.
Sorry, we can't take a chance that you'll have an bad reaction-I'm going to get the doctor and let him decide.
Talk to doc & he comes to bedside: I see here on the chart that you said to the nurse to report the redness where you got the injection of morphine as an allergic reaction, is that the way it was?
No, the nurse must have misunderstood me.
Pt on other side of curtain yells out : everyone here heard her yell at the nurse to report it as an allergic reaction, she hasn't shut up for over a half hour now.
Doc: Sorry, but we can't give you anything that you might have an allergic reaction to.
I'm leaving, nobody listens to me, nobody cares about all the pain I'm in and how I can't walk (while standing up, putting clothes on over the gown and trying to storm out)
THIS IS A TRUE STORY (I left out some things and changed /deleted medications that might be too specific to the patient).

I am 47 years old and have the following things wrong with my lower back: Spondylolisthesis, severe degenerative disc disease, 3 herniated discs, 1 torn disc, several Tarlov cysts, and spinal stenosis. I am in moderate to severe pain 24/7. Here's my experience with pain management:
I live in a small rural community that has 1 small hospital and 1 pain management doc. My pain doc gives me Hydrocodone 10mg 60 pills/month. He says that 1 pill q 12 hrs. should control my pain. Last month I began suffering excruciating pain at work that a hydrocodone wouldn't touch and my coworkers insisted on taking me to the ER. After being made to sit in a holding room for 3 hours, a PA finally came in a said, "Okay, what's the problem? A pulled muscle?" I proceeded to tell him all of the things that were wrong with my back. Before I go on, let me tell you that I have not been in this ER for the last 10 years for anything except a case of food poisoning for which I was admitted, so I'm not a frequent flyer. In fact, I've only been to 1 ER ever for my back and the last time was 4 years ago at an ER in Florida. Anyway, the PA says he'll give me something to "calm you down" (I guess because I was crying in pain). 45 minutes later a nurse comes in bearing a syringe. Verbatim she says, "Roll over", jams in the needle, hands me a prescription and walks out. This nurse (if you can call her that) acted as though I was a piece of dirt on the floor. My boss, who was there with me, goes to the desk and asks if we can leave. After we get in the car, he pulls the prescription out of his pocket and it's a script for Phenergan. Phenergan! I'm not sure what they gave me IM but it did ease the pain for about 3 hours.
After this episode in the ER, I made up my mind that I would lie at home and die before I ever stepped foot in that hospital again. I've also decided that there are docs and nurses who have no clue how to treat pain and really couldn't care less if they learn. My quality of life is practically nil, I know I have some major depression going on, I can't do anything I used to enjoy and have nothing in life to look forward to. Has the medical profession let me down? You're darned tootin'! Have I lost faith in doctors and nurses? You bet your bottom dollar! I quit nursing because of my back problems and have never regretted it. In the hospital where I used to work, patients were routinely undermedicated and it would kill me to witness the suffering and not be able to do anything about it. That was years ago and obviously nothing has changed in pain management. Thanks for letting me vent and try to remember my story the next time you treat someone in pain.

After a friend read my post, she pointed out some info that I should have included:
I've been to one of the top neurosurgeons in the U.S. He says my condition is too severe for surgery. I've have 3 series of epidurals, a nerve root block, lots of physical therapy, taken Neurontin, Indomethecin, Dolobid, antidepressants, and many other NSAID's. I've used TENS units and I've seen orthopedic specialists. A few docs that I've seen have said, "I know you're miserable" but none of them seem to want to do anything about it. I don't even discuss my back problems with my PCP because she thinks my back is "not that bad". I've not been to another pain management doc because the nearest one is over 100 miles away and it's very painful for me to travel that far in a car plus I guess I've just run out of faith that any doctor is going to help me. Am I just being a baby with a low pain tolerance? Maybe, but I don't think so. One orthopedic doc told me that I should feel lucky that this is all that's wrong with my back! In my previous post I stated that I had nothing to live for but that was wrong. I truly live in hopes that I will die soon because living life in this condition is not really living at all. Again, thanks for letting me vent and if anyone, anywhere has any suggestions, I'm waiting and watching.

I'm a new nurse on the list so please pardon my ignorance. I was quite interested in the pain links and explored several and probably will use some for staff training. I did not see any mention of dealing with chemically dependant people who may or may not be having pain. I work in a mental health facility which also serves chemically dependant people. We have a constant struggle with determining who is in pain and who is drug-seeking. We have isolated a few cues, but over-all are probably treating the wrong patients. Does anyone on this list have ideas on this subject, who can steer me to a few resources? I appreciate all the help offered.

Like most of the other nurses said, you have to medicate them if they have pain meds ordered. But, in the real world, there are people that are actual drug-seekers. Like, for instance, I had one patient that was sound asleep when I went into his room one night. Well, I messed around and made a little too much noise and he woke up. Well, he could get his medicine every 2 hours, so he called. When I went in there, he started "ooohhhhh, ooooooo, ahhhhhhh!" You know, as if to make me believe he was in extreme pain and "deserved" his pain medicine. Now this was the same man that was sound asleep until I woke him up. He wasn't making any noise and he was snoring. I'd say, he probably was a drug seeker. He watched the clock and got his pain med on the dot. We know that pain is not regular. It doesn't come and go by the clock.

Another sign I've seen that has indicated drug-seeking is a patient that feels the need to explain why they need the pain medicine. If you are hurting, then I don't need to know your reasoning behind the pain. Just get the medicine and go back to sleep. It's as if they feel guilty about their charades. Oh, and they will often have "nausea" at the same time they're hurting so they can get Phenergan. It potentiates the euphoria from the pain meds.

While I don't agree with drug-seekers taking advantage of hospitals to carry on their habits, I just do as orders dictate. Do I sometimes get annoyed when I see drug seekers getting adequate pain meds and true cardiac, gastro, and neuro patients only can't even get a simple Tylenol? Yes, I do. Do I get tired of running up and down the hall pushing drugs every hour of my shift when I have critical people under my care that need more attention? Yes, I do. Do I get frustrated when I see drug seekers in the parking lot with their IV poles going to smoke and then coming back in "writhing" in pain just minutes later? Yes, I do. Is there anything I can do about it? No.

I feel that drug-seeking has a more underlying cause. I don't feel that these people are often in physical pain so much as emotional pain. They are lacking something emotionally and cannot cope. The drug's euphoria takes them away for a brief time. I think it's a sad world when people cannot use the coping mechanism that God gave us and turn to drugs to mask the pain.

Someday, Nursing will accept that pain is whatever the individual experiencing pain says it is. Why do we persist in this need to control an issue that is out of our hands, namely a patient's report of pain? There is no way to measure pain through biomechanical means, no magic machine that pinpoints the exact site or severity of pain. Pain is completely subjective, yet there are those in Nursing who simply can't or won't accept the fact that we don't have the ability to say "Yes, here is proof you have or haven't pain" with any reliability.

Patient's with a history of drug use/abuse can certainly develop a tolerance to opioid narcotics which require that they receive a dose higher than that of an opioid naive patient. This does not mean that individual is making their pain up and even if they are, again, Nursing cannot accurately assess this. The best we can do is administer pain medication as ordered once we've assessed our patient to determine there is no respiratory depression, and continue to monitor and intervene if it becomes apparent that an individual is overmedicated. Patient's who are awake do not code from respiratory depression, especially not with the dosage of opioid generally ordered. This is not to say Nursing should be cavalier in administering narcotics. We need to realistically look at our patient's level of sedation in relationship to the amount of narcotics they've been receiving and, with our critical thinking skills, assess the effectiveness of their pain management and treat them accordingly.

People in pain may or may not display behaviors that we consider indicative of "being in pain." Coping mechanisms such as distraction or avoidance, may often mask a person's true pain level. I believe that if health care professionals expect someone in pain to act a certain way, some patient's learn to adopt those very behaviors. They become concerned that if they don't "look" as if they are having pain, their report of pain won't be believed and they won't receive the proper pain management. What exactly does that say about our practice?

So long as a patient has appropriate respirations and arouses easily, their report of pain should be believed and appropriate measures taken to alleviate it. Pain assessment, including sedation and respiration, should be ongoing to determine efficacy of the medications and ensure no undesirable effects are occurring.

The American Society of Pain Management Nurses has a website with research based information for Nurses to better care for their patient's in pain.

It's not as simple as that. I feel that by saying we just need to give pain meds as long as their respirations are within normal limits is not getting to the route of the problem for most of our patients. We as nurses need to start delivering holistic care of our patients.

Sure, there are people that are in "acute" pain due to illness/disorders. We need to treat the pain and monitor the reactions to the pain meds. But for people are "frequent" fliers or have chronic pain, there often lies a deeper reasoning behind their perceived pain. A lot of these people are having some mental issues. As you may well know, mental anguish/disorders can cause one to perceive physical pain. I think the so-called "drug-seeker" should all have a psych consult. Obviously, we are not dealing with the real issue just by medicating the patient. If they are coming back often, then that's not enough. There's deeper issues involved there. We need to get back to a holistic approach of care and treat the whole person. You need mental health in order to have physical health. We need to stop just treating in a problem-oriented way and delve deeper, ya know?